Diagnosis and Management of Chronic Daily Headache

Ivan Garza, M.D.,1 and Todd J. Schwedt, M.D.2

ABSTRACT

Chronic daily headache (CDH) is a descriptive term that encompasses multiple headache diagnoses and affects 4% of the general adult population. Chronic daily headache results in signiﬁcant pain and suffering with substantial impact on quality of life, and enormous economic costs to society. Although most patients with primary CDH suffer from chronic migraine or chronic tension-type headache, other primary and secondary headache disorders can also manifest as a CDH syndrome. For CDH management to succeed, secondary headaches need to be ruled out with proper investigations when judged necessary. If the diagnosis of primary CDH is established, diagnosis of the speciﬁc CDH subtype is imperative to institute appropriate treatment. The diagnosis and management of distinct CDH entities, chronic migraine, chronic tension-type headache, new daily persistent headache, and hemicrania continua, are the primary forms of CDH and the emphasis of this review. Although, strictly speaking, medication overuse headache is a secondary form of CDH, it is also highlighted in this review given its frequent association with primary CDH.

KEYWORDS: Chronic, daily, headache, migraine, hemicrania

Chronic daily headache (CDH) is a descriptive include female sex, low socioeconomic status, unmarried, term that encompasses several different headache diag- history of head or neck trauma, and the presence of noses. Chronic daily headache affects 4% of the adult comorbid pain disorders. Modifiable risk factors for population in the United States and around the world.1–3 CDH include obesity, snoring and other sleep disorders, The vast majority of CDH patients suffer from either high caffeine intake, smoking, and overuse of abortive chronic migraine or chronic tension-type headache. headache medications.6–9 Chronic daily headache results in significant pain and Similar to all headache types, it is essential to suffering, reduction in quality of life, and enormous exclude a secondary headache as the cause of CDH. economic costs to society.4,5 Depending upon the clinical history and examination Scher has summarized the evidence from popu- findings, further diagnostic testing may or may not be This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. lation-based studies related to risk factors influencing necessary. Although a complete list of causes for secon- the incidence, prevalence, and prognosis of CDH.6 dary CDH would be exhaustive, Table 1 summarizes Major life changes (residence change, marital status, common considerations. etc.) have been associated with the onset of CDH.7 If secondary headaches are ruled out, the clinician Nonmodifiable factors that increase the risk for CDH must determine the type of primary CDH the patient

1Department of Neurology, Mayo Clinic, Rochester, Minnesota; Headache; Guest Editor, Jerry W. Swanson, M.D., F.A.C.P. 2Washington University Headache Center, Washington University Semin Neurol 2010;30:154–166. Copyright # 2010 by Thieme School of Medicine, St. Louis, Missouri. Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, Address for correspondence and reprint requests: Ivan Garza, USA. Tel: +1(212) 584-4662. M.D., Assistant Professor, Department of Neurology, Mayo Clinic, DOI: http://dx.doi.org/10.1055/s-0030-1249224. 200 First Street SW, Rochester, MN 55905 (e-mail: garza.ivan@mayo. ISSN 0271-8235. edu). 154 DIAGNOSIS AND MANAGEMENT OF CHRONIC DAILY HEADACHE/GARZA, SCHWEDT 155

Table 1 Secondary Chronic Daily Headache patients suggest persistent activation of the trigemino- 16 Medication-overuse headache vascular system. Neurogenic inflammation may lead Cerebrovascular disease (cerebral venous sinus thrombosis, to central sensitization, a process implicated in the arteriovenous malformations, giant cell arteritis, subdural chronification of migraine. Functional and structural hematoma, etc.) brain changes have been identified in migraine and are Altered CSF dynamics (spontaneous CSF leak, idiopathic positively associated with increasing headache fre- 17 intracranial hypertension, secondary intracranial quency and duration. Chronic migraine sufferers hypertension) have increased iron deposition in the periaqueductal 18,19 Intracranial space-occupying lesions (neoplasms, others) gray, putamen, globus pallidus, and red nucleus. Posttraumatic They have reductions in gray and white matter density 20–22 Infection (intra- or extracranial, sinusitis) and volume in multiple regions of the brain. Musculoskeletal (cervical spine disorders, temporomandibular Migraine sufferers have inferior executive function joint disorders) andabnormalvisualmotionperceptionevenwhen 23,24 Others headache free. CSF, Cerebrospinal fluid. Diagnosis has. Chronic migraine, chronic tension-type headache, Chronic migraine patients tend to have mild to moder- new daily persistent headache, hemicrania continua, and ate headaches associated with mild migrainous features medication overuse headache are discussed in this re- (e.g., photophobia, phonophobia) with superimposed view. Although medication overuse headache is a sec- more-severe headaches associated with more prominent ondary CDH, it is included here because of the migraine features (‘‘full-blown’’ migraines). In some important contribution to primary CDH. patients, environmental hypersensitivities persist even during headache-free periods.25 This may include mild photophobia, phonophobia, motion-sensitivity, and cu- CHRONIC MIGRAINE taneous hypersensitivity/allodynia. Patients with chronic Chronic migraine, which affects 2% of the world migraine have an increased frequency of comorbid psy- population, places a substantial burden on individuals chiatric disorders, sleep disorders, fatigue, other pain, and societies.10 Chronic migraine results in poorer and gastrointestinal complaints. Recognition and treat- quality of life and causes significant disability.11,12 The ment of these comorbidities can result in improved World Health Organization considers chronic migraine health, greater quality of life, and may potentially result to cause disability on par with the disability secondary to in higher migraine treatment success rates. The follow- quadriplegia, dementia, and active psychosis.13 Direct ing are the recently revised diagnostic criteria for chronic and indirect costs from migraine are estimated at more migraine26: than $20 billion annually in the United States, much of which is due to chronic migraine.4 The average annual 1. Headache (tension-type and/or migraine) on 15 days cost per person with chronic migraine is more than four per month for at least 3 months times that associated with episodic migraine ($7750 2. Occurring in a patient who has had at least five attacks versus $1757).14 fulfilling criteria for migraine without aura Progression from episodic migraine (<15 head- 3. On 8 days per month for at least 3 months, headache ache days/month) to chronic migraine is referred to as has fulfilled criteria for pain and associated symptoms ‘‘transformed migraine.’’ In population studies, 3% of of migraine without aura (Criteria a and b below) or those with infrequent episodic headaches transform to was treated and relieved by triptan(s) or ergot before This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. CDH each year; 6% transform to frequent episodic the expected development of symptoms listed in headaches.1,15 In clinic-based studies, 14% of those Criteria a and b. with episodic migraine transform to chronic migraine a. Has at least two of the following: each year. Modifiable and nonmodifiable risk factors for i. Unilateral location this transformation have been described.15a ii. Pulsating quality A detailed discussion of migraine pathophysiol- iii. Moderate or severe pain intensity ogy is discussed in the article by Dr. Cutrer in this issue. iv. Aggravation by or causing avoidance of routine Interictal (between migraine) and longitudinal studies physical activity of chronic migraine will hopefully lead to an improved b. Has at least one of the following: understanding of the pathophysiology and effects of i. Nausea and/or vomiting transformation from episodic migraine to chronic mi- ii. Photophobia and phonophobia graine. Elevated concentrations of vasoactive neuro- 4. No medication overuse and not attributed to another peptides in the cerebrospinal fluid of chronic migraine causative disorder 156 SEMINARS IN NEUROLOGY/VOLUME 30, NUMBER 2 2010

Treatment Gabapentin Gabapentin has been studied as a pro- The treatment of chronic migraine focuses on prophy- phylactic medication for chronic daily headache in a lactic therapies, which may include avoidance of mi- multicenter randomized placebo-controlled crossover graine triggers, pharmacotherapy, physical therapy, study of 133 subjects (85% with migraine).29 Gaba- biobehavioral therapy, and others. Simultaneous use of pentin 2400 mg per day was associated with a greater these different therapeutic modalities may be needed. percentage of headache-free days (mean 26.6% Identification and treatment of comorbid disorders is vs. 17.5%, p < 0.001) and reductions in headache dura- also required for true treatment success. Acute headache tion, severity, and analgesic use. medication use needs to be limited to avoid medication overuse headache. Although complete headache eradi- Tizanidine Tizanidine has been studied as an adjunc- cation is not a realistic expectation, significant reductions tive prophylactic for chronic daily headache in a multi- in headache frequency and/or severity are the goal of center, randomized, blinded, placebo-controlled study.30 prophylactic therapy. One hundred thirty-six subjects (3/4 with chronic migraine) were randomized to placebo or to tizanidine PHARMACOLOGIC PROPHYLAXIS titrating up from 2 mg each night to the maximum Prophylactic medications used to treat episodic migraine tolerated dose, or 24 mg divided among three daily are also used for the prevention of chronic migraine. doses. The median tizanidine dosage was 20 mg per Thus, first-line prophylactic medications are from the day. Subjects in the tizanidine group had significant following classes: antidepressants, antiepileptics, and reductions in headache index as compared with the antihypertensives. The prophylactic medications that placebo group. have been specifically studied in clinical trials of patients with chronic migraine are illustrated in Table 2. Once an Fluoxetine Sixty-four subjects with chronic migraine effective prophylactic medication is found, it is typically were randomized in a 16-week double-blind trial of continued for 3 to 6 months prior to attempting dis- fluoxetine.31,32 Subjects were treated with 20 mg daily continuation. An effective prophylactic medication is and then increased to 40 mg daily if needed and as one that decreases headache frequency by at least 50%. tolerated. Fluoxetine-treated subjects had significant improvements as compared with the placebo group in Topiramate Two randomized, double-blind, placebo- overall headache status, mood, and headache frequency. controlled studies are available.27,28 The larger of the two studies randomized 153 subjects to topiramate 100 Amitriptyline Thirty-nine transformed migraine sub- mg daily and an equal number to placebo.27 Those in the jects participated in a prospective double-blind study of topiramate group experienced a reduction of 6.4 5.8 amitriptyline versus amitriptyline plus fluoxetine.32 headache days per month from a baseline of Although there were not significant differences in out- 17.1 5.4 days, as compared with a reduction of comes between the two treatment groups, subjects treated 4.7 6.1 days from a baseline of 17.0 5.0 days in the with amitriptyline (8–40 mg/day) and those treated with placebo group (p ¼ 0.10). In the smaller of the two amitriptyline plus fluoxetine (8–20 mg/day) both had studies, 32 subjects were randomized to topiramate reductions in headache frequency and intensity. 100 mg daily and 27 were randomized to placebo.28 Among all subjects, topiramate significantly reduced the Levetiracetam An open-label study of 36 transformed mean number of monthly migraine days during the third migraine subjects, with or without medication overuse, month of therapy as compared with placebo (p ¼ 0.02). investigated the effect of levetiracetam.33 At 3 months,

Table 2 Prophylactic Agents Studied Specifically in Chronic Migraine This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. Initial Dose Typical Total Drug (mg) Daily Dose (mg) Common Side Effects Serious Side Effects

Topiramate 25 100–200 Paresthesias, fatigue, weight loss Acute angle closure glaucoma, metabolic acidosis, hyperthermia Gabapentin 300 900–2400 Dizziness, somnolence, fatigue, edema Tizanidine 2 6–24 Somnolence, dry mouth, asthenia Hepatitis Fluoxetine 10–20 10–80 Insomnia, asthenia, tremor Prolonged QT interval Amitriptyline 10–25 50–150 Sedation, weight gain, constipation Cardiac dysrhythmias Levetiracetam 250 750–2000 Somnolence, asthenia Divalproex sodium 250–500 500–1500 Weight gain, tremor, nausea, alopecia Pancreatitis, liver failure, thrombocytopenia Memantine 5 5–20 Dizziness DIAGNOSIS AND MANAGEMENT OF CHRONIC DAILY HEADACHE/GARZA, SCHWEDT 157 levetiracetam-treated subjects had reductions in head- CHRONIC TENSION-TYPE HEADACHE ache frequency (24.9 days/month to 16.2 days/month; Chronic tension-type headache is considerably less prev- p < 0.001), disability (MIDAS dropped from 62.8 to alent than episodic tension-type headache.44 A tele- 40.8; p ¼ 0.01), and HIT-6 score (63.4 to 59.4; phone survey obtained from 1993 to 1994 in p 0.01). Baltimore, Maryland, found an overall prevalence of 38.3% for episodic tension-type headache and a 1-year Valproate Two studies suggest valproate may be useful period prevalence of chronic tension-type headache of in the prophylaxis of chronic migraine. In an open-label 2.2%.44 Chronic tension-type headache increases in study of 30 patients with intractable transformed mi- prevalence until the fourth decade of life and then graine, patients were maintained on dosages between decreases. Chronic tension-type headache is more prev- 1000 to 2500 mg.34 A 50% or greater reduction in alent in women compared with men and psychiatric headache index was found in 67% of the subjects, head- disorders may be risk factors for its development.44–48 ache-free days per month increased from 5.5 to 17.7, and Although peripheral mechanisms apparently play days with significant disability declined from 22 per a role in episodic tension-type headache pathophysiol- month to 8.5 per month. The second study was a chart ogy, central mechanisms may play a larger role in chronic review of 138 chronic daily headache patients (49 with tension-type headache.49,50 Chronic tension-type head- transformed migraine) being treated with divalproex ache sufferers had a general hypersensitivity to pain sodium monotherapy.35 In the migraine patients, the stimuli not seen in controls in a study of nociceptive mean decrease in migraine frequency was 65.2%. processing.51 Central pain inhibition may be dysfunc- tional in chronic tension-type headache. Research using Botulinum Toxin Although botulinum toxin type A high-density electroencephalogram (EEG) brain map- appears to benefit a subset of patients with chronic ping has found the supraspinal response to muscular pain migraine, no consistent or strong evidence is available to be abnormal in chronic tension-type headache suffer- yet to permit drawing conclusions on its efficacy in CDH ers.52 The reduced magnitude during and after induced (mainly transformed migraine).36 Further study results tonic muscle pain in controls, but not in chronic tension- are required and pending. type headache patients, might be a consequence of impaired inhibition of the nociceptive input in chronic Memantine Memantine was recently reported to in- tension-type headache.52 Deficient diffuse noxious induce remission of chronic migraine.37An open-label hibitory control-like mechanisms, such as seen in gen- study further suggests this drug may play a role in eralized chronic pain like fibromyalgia, have been found chronic migraine management.38 Double-blind studies in chronic tension-type headache.53 Voxel-based are required to establish memantine’s role in chronic morphometry and magnetic resonance imaging (MRI) migraine treatment. have identified a significant gray matter decrease in regions involved in pain processing in chronic tension- NONPHARMACOLOGIC THERAPY type headache patients.54 Biofeedback, relaxation therapy, cognitive–behavioral therapy, and physical therapy may be useful as adjunctive treatments for chronic migraine. A controlled study of Diagnosis biofeedback showed associated decreases in oxidative Because it largely consists of head pain alone, tension- stress and disability from migraine.39 Cognitive–behav- type headache is frequently called ‘‘the featureless head- ioral therapy may provide short-term and long-term ache.’’49 Chronic tension-type headache typically evolves reductions in headache burden.40 Physical therapy is from episodic tension-type headache55 and is usually associated with significant reductions in migraine bur- bilateral, pressure-like in quality, and mildly to moder- This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. den in some studies.41 Furthermore, a combination of ately intense. ‘‘Wearing a tight hat, wearing a tight band physical therapy and biofeedback has been shown to around the head, or wearing a heavy burden on the head’’ provide greater relief than physical therapy alone.42 are frequent descriptions used by patients.56 The following are current International Classification of Headache Disorders, 2nd edition (ICHD-2) criteria for chronic Outcome tension-type headache.55 Patients with chronic migraine may revert back to episodic migraine. Reversion rates at one year range 1. Headache occurring on 15 days per month on from 56 to 70% in population-based and specialty head- average for >3 months (180 days per year) and ache clinic-based samples, respectively.9,43 Predictors of fulfilling criteria 2–4 reversion include withdrawal of overused medications, 2. Headache lasts hours or may be continuous compliance with prophylactic medications, and regular 3. Headache has at least two of the following character- physical exercise. istics: 158 SEMINARS IN NEUROLOGY/VOLUME 30, NUMBER 2 2010

a. Bilateral location Protriptyline Twenty-five adult female chronic ten- b. Pressing/tightening (nonpulsating) quality sion-type headache sufferers were studied using protrip- c. Mild or moderate intensity tyline 20 mg every morning. Eighty-six percent had d. Not aggravated by routine physical activity such as fewer headaches per month, and 73% had a 50% walking or climbing stairs reduction in headache attacks per month.63 In contrast 4. Both of the following: to the weight gain associated with other tricyclic anti- a. No more than one of photophobia, phonophobia, or depressants, patients lost slightly over three pounds mild nausea during the study.63 No placebo group was used. b. Neither moderate or severe nausea nor vomiting 5. Not attributed to another disorder Mirtazapine Bendsten studied mirtazapine in a randomized, double-blind, placebo-controlled, crossover Of note, the presence of migraine attacks super- trial. Mirtazapine 15 to 30 mg/day or placebo was given imposed on a background daily ‘‘tension-type’’ headache for 8 weeks separated by a 2-week washout period.60 could suggest that chronic migraine may be the right Mirtazapine reduced the area-under-the-headache curve diagnosis rather than chronic tension-type headache.57 by 34% more than placebo. The drug also reduced headache frequency, duration, and intensity significantly more than placebo. The efficacy of mirtazapine was Treatment similar to that of amitriptyline (a therapeutic gain of Pharmacologic prophylaxis is the mainstay of treatment. 30%).59,60 Similar to chronic migraine, effective therapy is continued for at least 3 to 6 months prior to attempting discontin- Topiramate In an open study, topiramate (daily dose uation.58 Table 3 summarizes prophylactic medications 25 to 100 mg/day) resulted in a 50% reduction in studied specifically in chronic tension-type headache. headache frequency in 73% of 46 chronic tension-type headache patients at weeks 13 to 24.64 Average headache PHARMACOLOGIC PROPHYLAXIS intensity decreased from 6.13 to 2.07 on the visual analogue scale.64 Randomized controlled trials are Amitriptyline Amitriptyline is the drug of choice, needed to define topiramate’s role in the management typically at doses ranging from 25 mg to 100 mg per of chronic tension-type headache. day.50 This is the only antidepressant used in chronic tension-type headache that has demonstrated statisti- Sodium Valproate Sodium valproate (500 mg twice cally significant benefit in several trials.58 Amitriptyline per day) was associated with greater reductions in pain has an estimated therapeutic gain of 30% based on frequency than placebo in 41 chronic tension-type head- published trials.59,60 ache subjects in a prospective, double-blind, randomized, placebo-controlled trial.65 The Visual Analog Scale Nortriptyline Nortriptyline has a more favorable side pain rating did not decrease in the active group. effect profile than amitriptyline.61 In a randomized placebo-controlled trial, patients with chronic tension- Tizanidine Tizanidine (6 to 18 mg/day in divided type headache who did not tolerate amitriptyline were doses) was found to be superior to placebo in a random- switched to nortriptyline at doses of up to 75 mg/day.62 ized, double-blind, crossover study in women with Both antidepressants produced larger reductions in chronic tension-type headache.66 A separate random- headache, analgesic medication use, and headache-re- ized, double-blind, parallel-group study, however, failed lated disability than placebo.62 to demonstrate superiority to placebo.67 To date, one This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.

Table 3 Prophylactic Agents Studied in Chronic Tension-type Headache Initial Dose Typical Total Drug (mg) Daily Dose (mg) Common Side Effects Serious Side Effects

Amitriptyline 10–25 25–100 Sedation, weight gain, constipation Cardiac dysrhythmias Nortriptyline 10–25 25–100 Sedation, weight gain, constipation Cardiac dysrhythmias Protriptyline 5–10 10–30 Sedation, weight change, constipation Cardiac dysrhythmias Mirtazapine 15 15–45 Somnolence, dry mouth Neutropenia Topiramate 25 100–200 Paresthesias, fatigue, weight loss Acute angle closure glaucoma, metabolic acidosis, hyperthermia Sodium valproate 250–500 500–1000 Weight gain, tremor, nausea, alopecia Pancreatitis, liver failure, thrombocytopenia DIAGNOSIS AND MANAGEMENT OF CHRONIC DAILY HEADACHE/GARZA, SCHWEDT 159 cannot draw firm conclusions for the potential role of male ratio is 3.5:1.81 In tertiary headache clinics tizanidine in chronic tension-type headache.58 throughout America, up to 50 to 80% of patients have medication-overuse headache.80 By far, migraine is the Others Citalopram and paroxetine have not proven most common primary headache disorder associated beneficial in chronic tension-type headache prophy- with medication-overuse headache. In a meta-analysis laxis.59,68,69 Further research is needed to determine summarizing 29 studies, 65% of 2612 patients with the potential efficacy of venlafaxine70 and buspirone.71 chronic medication overuse headache had migraine, There is no evidence for a beneficial effect of botulinum 27% had tension-type, and 8% had mixed or other toxin in chronic tension-type headache.72 type of primary headache.81 The risk for medication overuse headache devel- COMPLEMENTARY/ALERNATIVE TREATMENT opment differs with individual substances. Opioids, In chronic tension-type headache sufferers with coex- butalbital-containing analgesics, and aspirin/acetamino- istent depression, simultaneous treatment for both dis- phen/caffeine combinations are high risk; triptans are orders has shown benefit.73 Combination treatment is moderate risk; and NSAIDs are low risk.82 In a recent superior to pharmacotherapy or behavioral therapy longitudinal population-based study, any use of barbi- alone.58 Combination treatment with behavioral stress turates and opiates was associated with increased risk of management was more likely to achieve clinically sig- transformed migraine.83 Critical dose of opiate exposure nificant (50%) reductions in headache index scores was around 8 days per month, and the effect was more (64% of participants) than antidepressant medication pronounced in men.84 Critical dose of barbiturate ex- (38% of participants), stress management therapy posure was around 5 days per month and the effect was (35%), or placebo (29%) in a randomized placebo-con- more pronounced in women.84 Triptans and NSAIDs trolled trial of 203 chronic tension-type headache sub- induced migraine progression in those with high fre- jects.62 quency of migraine at baseline (10–14 days per month), The potential role of acupuncture in chronic but not overall.84 tension-type headache is yet to be defined. In one study, Multiple mechanisms may be involved in the relaxation training induced the best benefit compared development of medication-overuse headache.85 Devel- with acupuncture and physical training.74 The potential opment of medication-overuse headache appears to be role of hypnosis75 and structured massage76 remain to be restricted to those with underlying headache disorders as determined. Other noninvasive physical treatments with it does not develop de novo in those without headaches some evidence in chronic tension-type headache pro- who overuse the same medications.85,86 Neurophysio- phylaxis include spinal manipulation, cranial electro- logic studies have shown facilitation of trigeminal and therapy, transcutaneous electrical nerve stimulation somatic nociceptive systems in medication-overuse head- (TENS)/electrical neurotransmitter modulation combi- ache, mainly mediated at a supraspinal level.87 This nation, and automassage/TENS/stretching combina- suggests central sensitization (a process also involved in tion.77 migraine pathophysiology) may also be involved in medication-overuse headache pathophysiology. Studies using ACUTE PHARMACOLOGIC THERAPY 18-fluorodeoxyglucose positron emission tomography Simple analgesics and nonsteroidal antiinflammatory (18-FDG PET) have identified reversible metabolic drugs (NSAIDs) remain as the pillar of abortive treat- changes in pain processing structures and persistent ment in tension-type headache.50 Acetaminophen/iso- orbitofrontal hypofunction in migraine patients with metheptene/ dichloralphenazone frequently helps more coexistent medication overuse headache.88 Chronic mor- severe episodes not responding to NSAIDs. phine exposure results in increased descending facilitation from the rostral88 ventromedial medulla and increased This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. excitatory neurotransmission at the dorsal horn.89 Some- MEDICATION-OVERUSE HEADACHE times, substance addiction may be the base for medication Medication-overuse headache frequently coexists with overuse headache. Others appear to be treating pain and a primary CDH and can preclude effective therapy of the comorbid anxiety disorder with the same medication latter. In some cases medication overuse headache may (e.g., opiates).90 Out of 895 patients with medication be responsible for the development or maintenance of a overuse headache studied in a prospective fashion, 68% CDH syndrome78; in other cases, medication overuse is met three of five substance-dependence criteria according the result of frequent headaches. Prophylactic medica- to the Diagnostic and Statistical Manual of Mental Dis- tions for primary CDH are more likely to provide benefit orders, Fourth Edition (DSM-IV ) versus 20% in those following successful medication-overuse headache man- without medication-overuse headache.91 Fear of head- agement.79 ache, anticipatory anxiety, obsessive drug-taking behav- The prevalence of medication-overuse headache iors, and psychological drug dependence may also help in the general population is 1.5%.80 The female to induce and then sustain medication-overuse headache.90 160 SEMINARS IN NEUROLOGY/VOLUME 30, NUMBER 2 2010

Diagnosis or from a ‘‘reparative’’ change from treatment failure to As discussed earlier, medication-overuse headache pa- favorable response to medical management.79,92 tients typically have a primary headache disorder that increased in frequency and led to increased analgesic consumption and then medication-overuse headache. It Withdrawal of the Offending Medication is not uncommon for patients to take frequent analgesics During analgesic withdrawal, headaches frequently ex- solely to prevent a severe analgesic-withdrawal head- acerbate before starting to improve.89 Nausea, vomiting, ache.85 Medication overuse headache varies in its char- restlessness, anxiety, and sleep disturbances may also acteristics (severity, location, type) and is frequently occur during withdrawal.85,89 Withdrawal symptoms associated with nausea, asthenia, and cognitive difficulties usually last 2 to 10 days (mean 3.5 days),85 but can (impaired memory, poor concentration, irritability).80 If a endure for 2 to 4 weeks.89 Although many physicians CDH sufferer is taking analgesics more than 2 to 3 days prefer inpatient programs for withdrawal,85 most pa- per week on average, medication-overuse headache tients can be managed on an outpatient basis.89 A recent should always be suspected. The following are current prospective, randomized trial in patients with migraine ICHD-2 diagnostic criteria for medication overuse head- and superimposed medication-overuse headache showed ache. Please note that the type of medication overused is that simple, strong advice was as effective as structured important for proper diagnosis.80 inpatient and outpatient detoxification programs in achieving medication withdrawal.93 The mean success 1. Headache present on 15 days/month rate of withdrawal treatment at 1 to 6 months was 72.4% 2. Regular overuse for >3 months of one or more acute/ in a meta-analysis.85 symptomatic treatment drugs a. Ergotamine, triptans, opioids, or combination analgesic medications on 10 days/month on a reg- Bridging ular basis for >3 months Thegoalof‘‘bridging’’istoprovidesymptomaticrelief b. Simple analgesics or any combination of ergot- during acute medication withdrawal. No clear guide- amine, triptans, analgesic opioids on 15 days/ lines or consensus recommendations exist.94 Bridging month on a regular basis for >3 months without recommendations are based on case series, retrospective overuse of any single class alone chart reviews, prospective uncontrolled studies, and 3. Headache has developed or markedly worsened during expert opinion.89 Some studies support the use of medication overuse corticosteroids; others do not.95 Further randomized, placebo-controlled trials are needed to clarify the potential role of corticosteroids in medication-overuse Treatment headache management.96 Antiemetics are often pre- Abrupt drug withdrawal remains the treatment of choice scribed in addition to the following published strat- when dangerous physical withdrawal is not a concern.85 egies. Proper management of medication-overuse headache should include the following steps: ORAL Naproxen 500 mg twice a day until withdrawal is 1. Patient education complete97 2. Withdrawal of offending medication Naproxen sodium 550 mg twice a day for 2 to 4 weeks89 3. ‘‘Bridging’’ aimed at symptomatic relief during med- Naproxen sodium 550 mg twice a day for 1 week, then ication withdrawal once a day for 1 week89 4. Establish new acute and preventive headache treat- Prednisone 60 mg/day, decrease by 20 mg every 2 days This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. ment regimen (total 6 days)98 5. Follow-up and headache reassessment Prednisone 100 mg for 5 days96 6. Relapse prevention INJECTED Intravenous (IV) methylprednisolone 100 to 200 mg Patient Education every 12 hours for 2 to 3 days89,99 Patients with medication-overuse headache need to IV or intramuscular (IM) dexamethasone 8 to 20 mg/ understand that as long as they are overusing analgesics, day, tapering over 2 to 3 days98 headache preventives may be less effective or not effec- IV hydrocortisone 100 mg every 6 hours for 24 hours; tive at all.79,89 They need to be educated on why every 8 hours for 24 hours; then every 12 hours for analgesic overuse is detrimental. The majority of med- 24 hours98 ication-overuse headache patients benefit from drug Repetitive IV dihydroergotamine (DHE; inpatient): IV withdrawal. Benefit may be from the withdrawal alone metoclopramide 10 mg, followed by 0.5 mg IV DHE. DIAGNOSIS AND MANAGEMENT OF CHRONIC DAILY HEADACHE/GARZA, SCHWEDT 161

Doses adjusted based on headache severity and side headache affects women more than men with reported effects100 ratios of 1.3:1 and 2.5:1.0 and can essentially affect all Continuous IV DHE (inpatient): 3 mg of DHE in age groups.107–109 Peak age of onset is in the second and 1000 mL of normal saline at 42 mL/h by IV infusion third decades for women and the fifth decade in men.109 pump, totaling 3 mg of DHE administered at Overall mean age of onset is 35 years of age.108 Although constant rate over 24 hours101 new daily persistent headache is estimated to occur Subcutaneous DHE (outpatient): 1 mg twice a day for infrequently in the general population, the exact fre- 1 week followed by 0.5 mg twice a day for 1 week, or quency is unknown.108 In headache clinics, however, 1 mg twice a day for 1 week followed by 1 mg every 1 in 10 CDH patients have new daily persistent day for 1 week89 headache.110 IV valproate sodium: loading dose of 15 mg/kg followed The etiology of new daily persistent headache is by daily maintenance of 5 mg/kg every 8 hours for not well understood. Although the nature of the associ- 12 to 48 hours102 ations is unclear, infection, flu-like illness, surgery, and IV prochlorperazine starting with 5 mg to 10 mg every stressful life events may precede new daily persistent 8 hours, with dosage adjustment according to efficacy headache.109 How these may result in new daily persis- and side effects until headache-free99 tent headache is unknown and in many patients, no precipitating factors exist.108 Possible associations between new daily persistent headache and Epstein-Barr Establish Appropriate Headache Prevention virus (EBV), herpes simplex virus (HSV), and cytome- Whether pharmacologic prophylaxis should be started at galovirus (CMV) have been suggested but remain the time of medication withdrawal remains an ongoing unproven.109,111–114 dispute.103 Because most patients will require long-term preventives, the authors recommend starting such treatment at the time of withdrawal. Preventives are chosen Diagnosis according to the type of underlying primary headache The vast majority of patients (up to 82%) can vividly disorder. recall the exact date the headache started.109 In most, 80%, the pain is continuous.108,109 Pain intensity tends to be moderate, although many patients experience Follow-up and Headache Reassessment severe pain.109 Clinical features vary significantly. Head- Once the overused medications have been withdrawn, aches may have primarily migraine features (photopho- patients frequently return to a pattern of intermittent bia, nausea, etc.) or be ‘‘featureless’’ and reminiscent of headaches. These headaches need to be classified and chronic tension-type headache.107–109 Secondary head- treated accordingly. ache disorders, including those due to spontaneous cerebrospinal (CSF) leaks and cerebral venous sinus thrombosis, need to be ruled out.55,106 MRI of the brain Relapse Prevention with gadolinium and magnetic resonance venography Most relapses occur in the first year following (MRV) should be considered. Clinical judgment guides withdrawal.104 In general, avoidance of opiates and/ further investigations, if any. Current ICHD-2 diag- or butalbital for the regular management of primary nostic criteria for new daily persistent headache are as headache disorders is recommended. Limitations follows:55 for the frequency of analgesic intake should be ex- plained: triptan or combination analgesic use should 1. Headache for >3monthsfulfillingCriteria2 be limited to 9 or fewer days a month on average and through 4 This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. NSAIDs to 15 or fewer days a month to prevent 2. Headache is daily and unremitting from onset or from medication-overuse headache relapse.105 The identi- <3 days from onset fication and management of comorbidities (anxiety, 3. At least two of the following pain characteristics: etc.) that may contribute to medication overuse head- a. Bilateral location ache development and preservation are of paramount b. Pressing/tightening (nonpulsating) quality importance to prevent medication overuse headache c. Mild or moderate intensity relapse.90 4. Not aggravated by routine physical activity, such as walking or climbing stairs 5. Both of the following: NEW DAILY PERSISTENT HEADACHE a. No more than one of photophobia, phonophobia, or New daily persistent headache, one of the most treat- mild nausea ment refractory headaches, is a headache that begins one b. Neither moderate or severe nausea nor vomiting day and typically does not remit.106 New daily persistent 6. Not attributed to another disorder 162 SEMINARS IN NEUROLOGY/VOLUME 30, NUMBER 2 2010

Of note, although the above criteria reflect essen- etc.).122 Although not fulfilling the diagnostic criteria,55 tially a chronic tension-type headache phenotype, mi- a subgroup of patients with continuous one-sided head- grainous features are frequently reported.115 Diagnostic aches completely responsive to indomethacin do not criteria will likely be modified as knowledge about this have autonomic symptoms.123 Mild migrainous features disorder expands. may be present, and some patients develop superimposed headaches consistent with migraine headaches.124 Ipsi- lateral ocular discomfort or an ocular foreign body Treatment sensation and a superimposed stabbing headache (‘‘jabs New daily persistent headache can endure for many years and jolts’’) are often reported.118 ICHD-2 diagnostic (even decades) and can be disabling. Despite proper criteria are as follows:55 treatment, the headache frequently does not abate.106 Takase found treatment to be very effective in 27%, 1. Headache for >3 months fulfilling Criteria 2 through moderately effective in 3%, mildly effective in 20%, and 4 not effective in 50% of 30 new daily persistent headache 2. All of the following characteristics: sufferers.108 In agreement with other headache special- a. Unilateral pain without side-shift ists,116 we recommend classifying the dominant head- b. Daily and continuous, without pain-free periods ache phenotype, whether it is migraine or tension-type, c. Moderate intensity, but with exacerbations of severe and treat with preventives accordingly. pain New daily persistent headache has been reported 3. At least one of the following autonomic features to take one of the following courses: a self-limited one occurs during exacerbations and ipsilateral to the typically resolving without treatment within several side of pain: months, or a refractory course resistant to aggressive a. Conjunctival injection and/or lacrimation treatment.55 Although most patients are headache free at b. Nasal congestion and/or rhinorrhea 2 years in some series, in others (and in practice) new c. Ptosis and/or miosis daily persistent headache may be refractory to treatment 4. Complete response to therapeutic doses of indome- for many years.106–109,113 thacin 5. Not attributed to another disorder

HEMICRANIA CONTINUA Secondary headaches mimicking primary hemi- Hemicrania continua is a one-sided continuous head- crania continua (including response to indomethacin) ache of moderate severity with superimposed severe have been reported, including internal carotid artery exacerbations of pain often associated with ipsilateral dissection, unruptured aneurysm, pineal cyst, pituitary autonomic symptoms. The frequency of hemicrania tumor, ipsilateral mesenchymal tumor of the sphenoidal continua in the general population is unknown.117 bone involving the clinoid process at the base of the skull, Hemicrania continua may begin at any age, but peaks lung adenocarcinoma, and pontine stroke.125–130 Diag- in the third decade of life.118 It is twice as common in nostic studies must therefore be ordered as necessary. women than men.119 If hemicrania continua is suspected, an oral in- The pathophysiology of hemicrania continua is domethacin test can be used for the diagnosis of hemi- incompletely understood. However, a PET study of seven crania continua. One of several methods is as follows: patients with hemicrania continua showed signiﬁcant 50 mg twice per day for 3 days, 50 mg three times per day activation of the contralateral posterior hypothalamus for 3 days, 50 mg four times per day for 3 days. and ipsilateral rostral pons during baseline pain that Indomethacin response is typically fast. In a prospective were blocked by administration of indomethacin.120 study of 12 hemicrania continua patients, complete pain This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. PET in one patient with hemicrania continua without relief was obtained within 48 hours in all cases, within autonomic features, who had dorsal pontine activation 24 hours in 10 of the patients, and within 8 hours in but no hypothalamic activation, suggests that the hypo- nine.131 Completion of the test without headache reso- thalamus may play a role in autonomic activation, perhaps lution is considered a failed trial. via disinhibition of the trigeminal-autonomic reﬂex.121

Treatment Diagnosis Due to absolute response to indomethacin, it is the Hemicrania continua is a unilateral headache that is treatment of choice for hemicrania continua. The ap- continuous in nature. Continuous pain is generally propriate dose will vary among patients. The initial dose moderate in intensity. There are superimposed severe is that dose which results in resolution of headache, attacks of pain that last minutes to several days classically determined during the diagnostic indomethacin trial. associated with autonomic features (lacrimation, miosis, Oral doses ranging from 25 mg to 300 mg per day DIAGNOSIS AND MANAGEMENT OF CHRONIC DAILY HEADACHE/GARZA, SCHWEDT 163 have been reported effective. However, given adverse population, and dependency ratios. Bull World Health side effects of indomethacin, the lowest effective dose is Organ 2004;82(4):251–258 the desired dose. Periodic attempts to decrease the dose 14. Munakata J, Hazard E, Serrano D, et al. Economic burden should be made. Potential side effects from indometha- of transformed migraine: results from the American Migraine Prevalence and Prevention (AMPP) Study. Head- cin are numerous. Administration of indomethacin with ache 2009;49(4):498–508 food can reduce gastrointestinal side effects. Treatment 15. Katsarava Z, Schneeweiss S, Kurth T, et al. Incidence and with gastric mucosal protectants, such as proton-pump predictors for chronicity of headache in patients with inhibitors, may also decrease this risk and is common episodic migraine. Neurology 2004;62(5):788–790 practice. Many of these potential side effects are dose- 15a. Lipton RB. Tracing transformation: chronic migration related. Approximately one of three patients report side classification, progression, and epidemiology. Neurology effects attributable to indomethacin therapy.132 Contra- 2009;72(5 Suppl):S3–S7 16. Sarchielli P, Alberti A, Floridi A, Gallai V. 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